APPLICATION 1. AAFP membership # (REQUIRED):

2. First and Last Name:3. Current address

Street:City, State, Zip:

4.

5.

6.

Permanent address (if different from current address)Street:City, State, Zip:Email address (emails notifications are often caught in organization firewalls and spam filters –please provide a personal email address that is regularly accessed):

Cell phone #:Can you receive text messages on this phone? Yes No

INSTRUCTIONSIMPORTANT: Your application will not be considered unless you are an American Academy Family Physician (AAFP) member. Before completing application, read the AAFP Foundation Guidelines and Requirements and Terms of Agreement. Your answer can be typed directly into the shaded box, or you can “cut and paste” your answer from another document into the box. A note of caution: the format may change once pasted into the shaded box, so be sure to check! Mac users: Answers for Q15-18 will not appear if working in preview. Application Packet in PDF format is due by March 1, 2020, Midnight CT. Email familymedicineleads@aafp.org with the following three documents to complete the application process: Application Checklist: ☐Application ☐CV or Resume ☐ Letter of Recommendation (see Guidelines & Requirements)

Emerging Leader Definition: An emerging leader is an individual who has shown historical aptitude for leadership and has exhibited to others a strong potential for future leadership. An emerging leader has little formal training or experience with leadership and is motivated to gain additional leadership skills and experience.

Application Deadline: March 1, 2020, Midnight CTPage 1 of 3

7. Name and address of your medical school or residency program:Name:Address:City, State, Zip:

8. Name & email of your faculty advisor or residency team leader:Name:Email:

9. What will your training year be in July 2020: M2 M3 M4 PGY-1 PGY-2Other

10. Are you applying for a Family Medicine Leads Scholarship to attend National Conference inaddition to this opportunity? Yes No

11. How did you hear about this program? If more than one source, list and separate by comma.

12. Are you open to other leadership opportunities (separate from this program) within the AAFP oryour state chapter? If yes, may we share your contact information with them? Yes No

13. (STUDENTS ONLY) Have you made the decision to commit to Family Medicine? Yes No Maybe

14. Please rank all three of these leadership tracks, in order of preference, that will be offered at theFamily Medicine Leads Emerging Leader Institute, based on your interest:

Policy & Public Health Leadership (Learning key strategies to move our specialty into a position to optimize the future health of America—both politically and within local communities.) Personal & Practice Leadership (Remaining effective and focused as you transition to greater levels of responsibility, autonomy, power and expectations.) Philanthropic & Mission-Driven Leadership (Maximizing your impact as a physician leader as you increase your income, gain professional respect and choose among many organizational opportunities for involvement.)

Share your personal opinions and background (max 2000 characters w/spaces per questions 15-18): 15. We encourage all to apply and are committed to the development of future Family Medicine

leaders who reflect the rich diversity of the specialty and the patients served. Please describe thediversity that you personally would bring to the Family Medicine Leads Emerging Leader Institute.

16. What sorts of issues should Family Medicine leaders be talking about right now, but aren’t?

Leadership Track Preference:

Application Deadline: March 1, 2020, Midnight CTPage 2 of 3

18. Please provide a brief statement describing why you consider yourself an emerging leader. Anemerging leader is an individual who has shown historical aptitude for leadership and has exhibited to othersa strong potential for future leadership. An emerging leader has little formal training or experience withleadership and is motivated to gain additional leadership skills and experience.

19. I have already secured my medical school or residency program director’s pre-approval for myparticipation in this program in the event that I am selected. Yes(If you are currently a 4th year medical student, please notify your residency director once the match has occurred to ensure pre-approval is in place for consideration).

APPLICANT AGREEMENTBy electronically submitting this application for review, I agree that all information is correct and I have read the Guidelines and Requirements and will comply with the Terms of Agreement (as posted on www.aafpfoundation.org) should I become a Family Medicine Leads Emerging Leader Institute Scholar.

17. Doctors take care of patients, but do other things in their community as well. In a few sentencesexplain what is the most important role for the family physician of the future OUTSIDE of directpatient care?

Print Name Date

Application Deadline: March 1, 2020, Midnight CTPage 3 of 3